Westminster Rehabilitation And Wellness Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Westminster, Maryland.
- Location
- 1234 Washington Road, Westminster, Maryland 21157
- CMS Provider Number
- 215094
- Inspections on file
- 27
- Latest survey
- February 13, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Westminster Rehabilitation And Wellness Center during CMS and state inspections, most recent first.
A resident was not protected from abuse when a GNA slapped the resident on the buttocks twice while providing incontinence care. The incident was substantiated through the resident’s consistent statements, corroborating interviews, and confirmation that a witness GNA’s involvement aligned with the resident’s account, demonstrating that the resident was not kept free from physical abuse by staff.
Staff failed to promptly report an allegation of abuse and to submit investigation results within required timeframes. A resident, who believed they had a BM and used the call bell, was assisted by two GNAs; one allegedly slapped the resident’s bare buttocks twice and made a dismissive comment after finding no BM, while the other GNA witnessed the event but did not notify administration. The resident later disclosed the incident to another GNA, who reported it to administration, resulting in the allegation being reported to the State Survey Agency more than two hours after it was witnessed and the final investigative report being submitted more than five working days after the incident.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, due to lapses in safeguarding measures.
A resident with intact cognitive function reported missing several pairs of sweatpants, and despite notifying staff, the grievance was not resolved within the facility's required timeframe. Documentation showed incomplete follow-up and a lack of resolution, with staff interviews revealing unclear roles and insufficient action in addressing the resident's complaint.
A resident reported missing money from a locked nightstand drawer, and the facility's investigation was incomplete, lacking statements from all relevant staff shifts. The DON acknowledged that not all necessary staff were interviewed, resulting in insufficient documentation of the incident.
Licensed nursing staff documented the administration of an eye drop medication for a resident before the medication was delivered to the facility. Despite pharmacy delivery delays, several doses were signed off as given in the eMAR, and this was confirmed through interviews with an LPN and the DON, as well as a review of the medication audit trail.
A medical provider did not review or renew a resident's pain medication order, resulting in the discontinuation of as-needed Oxycodone for a resident with chronic pain. The provider later acknowledged the order's expiration was an error, and the DON confirmed the lack of review at the time. The resident experienced a lapse in pain management until the medication was reordered.
A resident with complex medical and psychiatric conditions experienced a delay in receiving prescribed eye drops for a new onset of eye redness, as the facility was waiting for pharmacy delivery over several days. Nursing staff and the DON confirmed ongoing issues with timely medication delivery from the pharmacy, requiring repeated follow-up and escalation.
A resident with neurological and psychiatric diagnoses was ordered eye drops for a change in eye condition. The eMAR showed that the drops were documented as administered by three nurses before the medication was actually delivered to the facility. Interviews and record audits confirmed the medication was not available at the time of documentation, resulting in incomplete and inaccurate medical records.
A resident with severe cognitive impairment and chronic pain was administered both tramadol and oxycodone, despite a physician's order to discontinue tramadol upon the arrival of oxycodone. This oversight occurred due to nurses overlooking the order, leading to the resident receiving both medications and subsequently exhibiting stroke-like symptoms.
The facility failed to report a suspected abuse incident involving a resident to the state agency within the required two-hour timeframe. The incident occurred in the resident's room, and although the facility's policy aligns with federal requirements for timely reporting, the report was submitted four hours after the incident. The DON confirmed the delay during an interview.
The facility failed to investigate a missing Oxycodone blister pack from a medication cart and did not document or interview involved staff. Additionally, an allegation of verbal abuse by a GNA was not investigated after a resident reported it via email to the administrator.
A resident did not receive a baseline care plan (BLCP) summary within 48 hours of admission, as required. The BLCP, essential for ensuring continuity of care and communication among staff, was not documented as provided to the resident. The DON confirmed the lack of documentation and emphasized the BLCP's role in guiding safe and accurate care from admission.
A resident with two pressure ulcers, one facility-acquired, did not have a person-centered care plan addressing mobility and skin integrity. The care plan lacked interventions for when the resident refused repositioning and did not include specific wound care interventions. The DON confirmed the absence of individualized care plans for the resident's needs.
A facility failed to meet a resident's personal hygiene needs, as they did not document or provide necessary assistance with activities of daily living. The resident, requiring maximum assistance due to medical conditions, reported inadequate cleaning and removal of their commode chair, impacting their dignity. Interviews revealed a lack of specific interventions to consistently meet the resident's needs.
The facility failed to notify the family of a deceased resident about the remaining balance in the resident's account within the required 30-day timeframe. The Business Office Manager confirmed that the notification was sent late, only the day before the survey.
A resident's medical information was left visible on an unlocked laptop screen on a medication cart in a hallway, unattended by an LPN. The LPN confirmed the screen should have been locked, and the DON stated that staff are expected to lock screens when away.
A facility failed to update a resident's care plan to reflect changes in their behavioral issues and refusal of nursing interventions. The resident, requiring maximum assistance with ADLs, expressed concerns about the removal of their commode chair, inadequate cleaning, and delayed staff responses. Despite these issues, the care plan was not revised to address the resident's reluctance to get out of bed or use a motorized wheelchair. The deficiency was discussed with the DON during the survey.
A medication cart was found unlocked and unattended in a hallway, contrary to the facility's policy. An LPN confirmed the cart was left unlocked, and the DON stated that carts should be locked when unattended.
The facility failed to maintain infection control practices, as evidenced by an uncapped Foley catheter drainage bag, unlabeled urinals without lids, and brown matter on a commode. Staff interviews revealed that urinals should be stored in residents' drawers and labeled, and cleaning supplies are accessible to nursing staff. Despite these protocols, the deficiencies indicate lapses in infection control.
The facility failed to adhere to professional standards in managing controlled medications, with discrepancies in narcotic counts and improper signing off by LPNs. Issues included mismatched pill counts, damaged medication packs, and missing signatures during shift changes. Staff interviews revealed non-compliance with facility policies for narcotic management.
The facility failed to ensure adequate kitchen staffing, affecting all residents. Observations and staffing schedules revealed consistent understaffing, with many shifts having fewer than the required 1 cook and 3 culinary aides. The facility assessment did not identify the necessary food and nutrition services staff needed.
The facility failed to monitor food temperatures, follow sanitary practices, store food properly, maintain dishwasher temperatures, and ensure an adequate food supply. Observations included incomplete temperature logs, unsanitary conditions, improper food storage, and insufficient milk supply. Interviews with staff confirmed these deficiencies.
The facility failed to employ a qualified social worker on a full-time basis. The Activities Director had been providing social work services since November 2023, despite not being a qualified social worker. The NHA confirmed that the facility, with a capacity of more than 120 beds, had not employed a full-time social worker since the previous one left at the end of January 2024.
The facility failed to meet at least quarterly to conduct required QAPI activities. Review of sign-in sheets revealed no QAPI meetings were held in November and December 2023 or January 2024. The NHA acknowledged the lapse and noted an Ad Hoc QAPI meeting was held in February 2024 to address the issue.
The facility failed to include dietary staffing in their facility-wide assessment, leading to inadequate kitchen staffing and operational issues. A staff member, originally in maintenance, was observed working as a culinary aide, and the Dietary District Manager was unfamiliar with the assessment. The facility assessment did not identify food and nutrition services staff needed, which was confirmed by the Administrator.
The facility failed to revise and update comprehensive care plans within seven days after completing assessments and did not hold timely care plan meetings with residents and/or their representatives. This deficiency was identified for five residents during the recertification survey.
The facility failed to address and review medical orders pending provider signature, provide timely care for residents with a change in condition, and arrange timely follow-up post-op visits. This affected multiple residents, leading to potential duplicate medication administration, delayed interventions for declining conditions, and missed follow-up appointments.
Two residents experienced delays in the uploading of medical records, including psychotherapy notes and consults, which were not documented within the facility's expected 72-hour timeframe. One resident's Acute Visit note was signed after the resident had already been transferred to a hospital, making it unavailable for review during a critical period.
A Geriatric Nursing Assistant (GNA) dragged a resident backwards on a shower chair through the hallway due to a broken footrest, failing to treat the resident with respect and dignity.
Facility staff failed to notify a resident's representative and physician of a diet change and new medication. The resident's diet was changed to dysphagia puree, and cough medication was prescribed without proper documentation or notification. Staff interviews revealed communication and documentation lapses.
The facility failed to inform and assist residents with establishing advance directives, as evidenced by the lack of documentation and conflicting responsibilities among staff. Interviews with staff confirmed the deficiency, highlighting a systemic issue in the facility's process.
The facility failed to notify residents or their representatives in writing of the reserve bed payment policy upon transfer to an acute care facility. The medical records of three residents showed that while the bed hold policy was mentioned, the daily payment amount for holding the bed was not included.
The facility failed to ensure a comprehensive care plan for a resident with pressure ulcers. The care plan did not include the resident's sacral wound, despite documented orders for daily dressing changes. This omission was confirmed by a registered nurse and reported to the Nursing Home Administrator.
A resident reported being roughly handled and improperly transferred using a Hoyer lift by a GNA without the required assistance of a second staff member. The GNA admitted to using the lift alone due to short-staffing, and the incident was confirmed through interviews and witness statements.
The facility failed to monitor and respond to a resident's significant weight loss, as a ten-pound difference within four days was not documented or reported to the physician. Interviews with staff revealed that such changes should be verified, followed up on, and reported, but this protocol was not followed.
A resident reported ineffective pain relief from prescribed Morphine and high pain scores, but the facility staff failed to evaluate the pain or adjust the management plan. Despite protocol requiring nurses to contact the provider for high pain scores, this was not done.
The facility failed to ensure that GNAs were competent with their skill sets, as three out of five randomly selected GNA employee files lacked records to support their competency. The orientation forms for these GNAs did not include signatures or documented dates, and Staff #4 confirmed the lack of supportive evidence for verifying their skills.
The facility failed to follow physician-prescribed parameters for administering blood pressure and pain medications to a resident. Blood pressure readings were not documented before administering Metoprolol, and pain medications were given outside the prescribed pain levels.
The facility failed to ensure proper supervision of the kitchen by a qualified dietetic service supervisor. The Culinary Director was not a Certified Dietary Manager, and the Registered Dietician, who worked 30 hours a week, was not responsible for the kitchen. The facility assessment did not identify the need for food and nutrition services staff, leading to a deficiency.
Facility staff failed to thoroughly investigate an allegation of abuse reported by a resident. The investigation included statements from staff not listed on the assignment sheet for the night in question, and the Nursing Home Administrator could not verify the incident date. Additionally, there was no documentation to support the investigation or a statement from the resident.
A resident with missing upper dentures did not receive timely dental care, despite a care plan meeting and assurances that a dentist would visit. The facility lacked documentation and was unaware of the dentist's recommendations, leading to a deficiency identified by surveyors.
The facility failed to document certifications of incapacity and ensure the accuracy of the MOLST form for a resident, and did not document pertinent information regarding surrogacy and guardianship disputes for another resident. These deficiencies were identified during a recertification survey.
The facility staff failed to ensure the results from the last annual survey were posted in accessible locations for residents and visitors. Survey results were not found in the indicated areas, and binders in the ACU nurses' station contained outdated surveys and were not readily accessible.
Failure to Protect a Resident From Physical Abuse During Incontinence Care
Penalty
Summary
Facility staff failed to protect a resident from physical abuse by a Geriatric Nursing Assistant (GNA). According to the facility’s investigation of a reported incident, on one evening after dinner and before 11:00 PM, during incontinence care, the resident was slapped on the buttocks twice by a GNA. The allegation of physical abuse was substantiated based on the resident’s statements, repeated interviews that produced a consistent recounting of the incident, and confirmation from police that a witness GNA’s involvement matched the resident’s consistent statements. The Director of Nursing acknowledged these findings during discussion with surveyors. This deficiency centers on the occurrence of physical abuse during the provision of incontinence care, as verified by the victim’s account and corroborating witness information, demonstrating that the resident was not kept free from abuse while under the care of the involved GNA.
Failure to Timely Report Alleged Abuse and Investigation Results
Penalty
Summary
Facility staff failed to immediately report an allegation of abuse to facility administration and the State Survey Agency and failed to submit the results of the investigation within the required timeframe. The incident involved a resident who believed they had a bowel movement and activated the call bell. Two GNAs responded; after determining the resident had not had a bowel movement, one GNA allegedly slapped the resident’s bare buttocks twice and made a remark implying the resident was “just playing.” This alleged abuse was witnessed by the second GNA, who did not notify facility administration at the time of the incident. The resident later reported the alleged abuse to another GNA, who then informed facility administration. The facility documented the incident as having occurred on a specific date and reported it to the State Survey Agency more than two hours after the alleged abuse was witnessed. Additionally, the facility’s final self-report of the investigation was submitted to the State Survey Agency more than five working days after the incident. The DON was informed of concerns regarding staff failure to report the witnessed abuse promptly and the late submission of the final self-report and acknowledged these concerns.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure a safe environment for all residents. Specific details about the actions or inactions that led to the deficiency, as well as information about the residents involved or their medical conditions at the time, are not provided in the report.
Failure to Resolve Resident Grievance Regarding Missing Personal Items
Penalty
Summary
The facility failed to maintain an effective grievance system as evidenced by its handling of a complaint regarding missing clothing for a resident. The resident, who was assessed to have intact cognitive function with a BIMS score of 14 out of 15, reported missing four pairs of sweatpants and stated that facility staff had not taken any action after being informed. The Director of Nursing (DON) acknowledged being aware of the complaint and documented the grievance, noting the specific items missing and that some clothing had been found while others remained unaccounted for. However, the section of the grievance form designated for resolution was left blank, and there was no documented resolution within the facility's stated timeframe for resolving grievances. Interviews with facility staff revealed a lack of clarity and follow-through in the grievance process. The Social Worker described her role as collecting grievances and distributing them to the appropriate staff, but indicated that missing items concerns were directed to the Administrator. Despite the facility's policy requiring grievances to be resolved within a reasonable timeframe, generally within five business days, the complaint regarding the missing clothing remained unresolved at the time of the survey. The Administrator confirmed that the grievance had not been resolved and acknowledged the need for process improvement.
Incomplete Investigation of Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to provide documentation that allegations of misappropriation of property were thoroughly investigated for one resident. The incident involved a resident who reported that money was missing from a locked nightstand drawer, which appeared to have been broken into. The resident was unsure of the exact time the theft occurred but believed it happened during the night while they were watching TV in the dining room. The facility's investigation included written statements from four out of five night shift staff and three out of eight evening shift staff, but did not include statements from the day shift staff who worked the following morning. During an interview, the DON confirmed that the investigation was incomplete, acknowledging that statements from all relevant staff, particularly those on the evening shift, were not obtained. The resident's account of the incident was noted to be inconsistent, but the lack of comprehensive staff interviews and documentation resulted in an incomplete investigation of the alleged misappropriation.
Medication Administration Documented Prior to Receipt
Penalty
Summary
Licensed nursing staff failed to meet professional standards of practice by documenting the administration of a medication before it was actually available in the facility. Specifically, a resident with multiple diagnoses, including cerebral infarction with hemiplegia, aphasia, and psychiatric disorders, was ordered to receive Polyethylene glycol eye drops for redness and dryness in the left eye. The medication was ordered and documented as not given on the first scheduled dose, with a corresponding note explaining the delay due to pharmacy delivery. However, subsequent doses were signed off as administered by nursing staff, despite the medication not being delivered to the facility until several days later. Interviews with the LPN who signed off on the administration and the DON confirmed that multiple nurses documented the medication as given when it had not yet been received. The audit trail in the electronic medical record verified that the medication was not dispensed to the facility until after the dates it was documented as administered. The NHA was made aware of the issue and acknowledged the concern during the surveyor's investigation.
Failure to Review and Renew Pain Medication Orders
Penalty
Summary
A medical provider failed to appropriately review and manage pain medication orders for a resident with chronic pain due to trauma. The resident was admitted with an order for Oxycodone 15 mg every 4 hours as needed for pain, which was subsequently reduced in dosage and frequency by the nurse practitioner responsible for pain management. The Oxycodone order was eventually set to expire after 21 days, and upon expiration, the medication was discontinued without a documented review or renewal by the provider. The resident had not received the as-needed Oxycodone for a period following the discontinuation, despite ongoing reports of pain. The nurse practitioner acknowledged during interview that the 21-day limitation on the Oxycodone order was an error and that the medication should have been ordered indefinitely until a formal reevaluation occurred. The DON confirmed that the provider did not review the resident's medication orders at the time the Oxycodone order expired. The resident later reported that the discontinued as-needed medication had been effective in controlling pain, which was no longer managed after the discontinuation until the order was eventually reinstated.
Failure to Provide Timely Physician-Ordered Medications Due to Pharmacy Delays
Penalty
Summary
The facility failed to provide physician-ordered medications in a timely manner to meet the needs of a resident. A resident with multiple diagnoses, including cerebral infarction with hemiplegia and hemiparesis, aphasia, generalized anxiety disorder, bipolar disorder, and major depressive disorder, was admitted in May 2024. On July 17, 2025, a change in condition was noted when the resident developed redness in the left eye, and a new order for Polyethylene glycol eye drops was prescribed. Documentation in the electronic Medication Administration Record (eMar) indicated that the medication was not available and the facility was waiting for pharmacy delivery. Over the following days, additional notes confirmed that the medication had still not been delivered, and staff continued to document the delay. Interviews with the DON and nursing staff confirmed ongoing issues with the pharmacy's timely delivery of medications. The DON acknowledged repeated problems, especially on weekends, requiring escalation to corporate and personal intervention to obtain necessary medications. Nursing staff reported having to repeatedly contact the pharmacy and sometimes order medications STAT due to urgent resident needs. The NHA was also made aware of the ongoing concerns regarding medication delivery delays.
Inaccurate Medication Administration Documentation Prior to Medication Receipt
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident reviewed during a complaint survey. The resident, admitted with multiple diagnoses including cerebral infarction with hemiplegia and hemiparesis, aphasia, and several psychiatric conditions, experienced a change in condition when redness was noted in the left eye. A new order for Polyethylene glycol eye drops was placed, but documentation in the electronic Medication Administration Record (eMAR) indicated that the medication was signed off as administered on several occasions before it was actually delivered to the facility. Interviews with nursing staff and review of the medication audit details confirmed that three nurses documented administration of the eye drops prior to their arrival at the facility. The LPN involved could not recall the specifics and acknowledged the possibility of documentation error. The Director of Nursing and Nursing Home Administrator both confirmed that the medication was not available at the time it was documented as given, resulting in inaccurate and incomplete medical records for the resident.
Failure to Discontinue Medication as Ordered
Penalty
Summary
The facility failed to follow the physician's orders for a resident's medication management, leading to the administration of both tramadol and oxycodone, contrary to the physician's directive. The resident, who had severe cognitive impairment and was admitted with conditions including deep vein thrombosis and chronic pain, was prescribed tramadol for pain management. The physician ordered that tramadol be discontinued once oxycodone was delivered to the facility. However, the facility did not adhere to this order, resulting in the resident receiving both medications. On the evening of the delivery of oxycodone, a registered nurse signed for the medication but did not discontinue tramadol as required. The following morning, another nurse administered both tramadol and oxycodone to the resident, who was experiencing significant pain. This oversight was acknowledged by the nurses involved, who admitted to overlooking the order to discontinue tramadol. The resident subsequently exhibited stroke-like symptoms, prompting a hospital evaluation. The medical director reviewed the case and noted that while the resident received the lowest doses of both medications, the tramadol should have been discontinued as per the physician's order. The medical director also stated that the combination of medications was not likely to have caused the stroke-like symptoms, but emphasized that the tramadol should have been discontinued upon the arrival of oxycodone.
Delayed Reporting of Suspected Abuse
Penalty
Summary
The facility staff failed to report an allegation of suspected resident abuse to the state agency within the required timeframe. The incident involved a resident and occurred in the resident's room at approximately 11:45 AM. The facility's policy and federal requirements mandate that such allegations be reported to the state agency within two hours. However, the initial report was sent at 3:47 PM, exceeding the two-hour window. During an interview, the Director of Nursing confirmed the procedure for reporting alleged abuse and acknowledged that the report was submitted late, four hours after the incident was reported to the facility's administration.
Failure to Investigate Allegations of Misappropriation and Verbal Abuse
Penalty
Summary
The facility staff failed to conduct a thorough investigation into an allegation of misappropriation of property involving a resident's medication. Specifically, a blister pack of Oxycodone was reported missing from a medication cart during a specific shift. The investigation lacked critical documentation, including the staffing sheet and an interview with the nurse who completed the narcotic count with the responsible LPN. The LPN confirmed the missing narcotics were from their cart and identified the outgoing nurse involved in the narcotic count, but no statement from this nurse was included in the investigation, and the nurse no longer works at the facility. Additionally, the facility did not investigate an allegation of verbal abuse reported by a resident. The resident had emailed the facility's administrator detailing a verbal encounter with a Geriatric Nursing Assistant, but this email was not included in the documents reviewed by the surveyor. The administrator confirmed that no investigation was conducted regarding the verbal abuse allegation, indicating a failure to address the resident's concerns appropriately.
Failure to Provide Baseline Care Plan Summary
Penalty
Summary
The facility failed to provide a baseline care plan (BLCP) summary to a resident within 48 hours of admission, as required. This deficiency was identified during a survey where it was found that a resident did not receive a BLCP summary, including a list of current medications, within the specified timeframe. The BLCP is crucial for ensuring continuity of care and communication among staff, as well as for increasing resident safety and preventing adverse events immediately following admission. During interviews and a review of the resident's electronic medical record, it was confirmed that there was no documentation indicating the resident had received the BLCP summary. The Director of Nursing (DON) acknowledged the absence of such documentation and reiterated the importance of the BLCP in guiding staff to provide safe and accurate care from the moment a resident is admitted. Despite the DON later providing a BLCP dated after the resident's admission, there was no evidence that the resident had been given a copy of the plan.
Failure to Implement Person-Centered Care Plan for Mobility and Wound Care
Penalty
Summary
The facility staff failed to initiate a person-centered care plan for a resident's mobility and wound care needs. During a review of the resident's electronic medical record, it was found that the resident had two pressure ulcers, one of which was acquired at the facility. The care plan lacked interventions for when the resident refused to be turned or repositioned, and there was no person-centered care plan addressing skin integrity. The care plan did not include specific interventions related to the resident's wound care and overall care needs. An interview with the Director of Nursing confirmed the absence of patient-centered care plans for the resident's mobility and skin integrity. The deficiency was identified in one of the four resident records reviewed for care plans, highlighting a failure to provide individualized care planning for the resident's specific needs.
Deficiency in Meeting Resident's Personal Hygiene Needs
Penalty
Summary
The facility failed to ensure that a dependent resident's personal hygiene needs were adequately met, as evidenced by the lack of documentation and assistance provided to Resident #2. This resident, who required maximum two-person assistance with activities of daily living due to a below-the-knee amputation, morbid obesity, and impaired mobility, did not receive documented assistance with personal hygiene during the night shift on 08.14.24. Additionally, there was no documentation of assistance with showering and bathing on multiple dates throughout August 2024. The resident expressed concerns about the removal of their commode chair, which was taken away after a fall, and reported that the GNAs did not clean their buttocks thoroughly after bowel movements, leading to discomfort and a negative impact on their dignity. Interviews with the unit manager and the director of nursing revealed a lack of specific individualized interventions to assist the resident with their ADL goals consistently. The unit manager noted that the resident often refused scheduled showers but stated that staff would try to accommodate the resident's requests for showers on other days. However, there was no evidence of consistent clinical interventions to address the resident's needs, particularly in light of their history of refusing ADL assistance. The director of nursing acknowledged the expectations for GNAs and nurses to use clinical interventions for residents with a history of refusing ADL assistance, but the facility's practices did not align with these expectations, leading to the identified deficiency.
Failure to Timely Notify Family of Deceased Resident's Account Balance
Penalty
Summary
The facility staff failed to notify the family of a deceased resident about the remaining balance in the resident's account. This deficiency was identified during a survey when the surveyor reviewed the account balances of residents' funds managed by the facility. It was found that the resident had passed away, and the notification to the family regarding the account balance was sent past the 30-day allotted timeframe. The Business Office Manager confirmed that the notification letter was sent to the family the day before the survey, which was beyond the required notification period.
Resident Information Privacy Breach
Penalty
Summary
The facility staff failed to protect the privacy of residents' medical information, as observed by a surveyor. During a survey, a laptop on a medication cart was left unlocked and open, displaying a resident's medication administration record (MAR) with prescribed medications visible. This occurred when a nurse was not present at the cart, leaving the information exposed for approximately one minute. Upon returning, the LPN acknowledged that the screen was left visible and confirmed that it should have been locked to protect resident information. The Director of Nursing stated that the facility's expectation is for staff to lock computer screens when leaving them unattended.
Failure to Update Resident Care Plan for Behavioral and ADL Needs
Penalty
Summary
The facility failed to appropriately revise the care plan for a resident as their care needs changed over time. Specifically, the care plan did not reflect the resident's current behavioral issues and refusal of nursing interventions, which were documented by a mental health nurse practitioner. The resident, who required maximum assistance with activities of daily living (ADLs), expressed concerns about the removal of their commode chair, inadequate cleaning after bowel movements, and the negative impact on their dignity due to staff's delayed response to requests. Despite these issues, the care plan was not updated to address the resident's reluctance to get out of bed or their refusal to use the motorized wheelchair. The surveyor's review of the resident's records revealed that the behavior contract and care plan had not been revised in 2024 to address the resident's current needs and behaviors. The care plan revision in August 2024 failed to include new individualized staff interventions to encourage the resident to participate in showers, out-of-bed activities, and mobility. The facility's deficient practices were discussed with the Director of Nursing during the survey and at the exit conference.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility staff failed to ensure medications were secured, as evidenced by an unlocked and unattended medication cart. This deficiency was observed by a surveyor who noted that one of the seven medication carts reviewed was left unlocked and unattended in the hallway. The surveyor observed the cart, located across from a specific room, with its locking mechanism in the unlocked position. Approximately one minute later, an LPN returned to the cart and confirmed that it had been left unlocked. The facility's Medication Administration policy explicitly states that medication carts should not be left unlocked. During an interview, the Director of Nursing confirmed that the expectation is for medication carts to be locked immediately when unattended.
Infection Control Lapses in Facility
Penalty
Summary
The facility staff failed to maintain proper infection control practices, as observed during a survey. An uncapped Foley catheter drainage bag was found hanging on the handle of the commode in a resident's bathroom. Additionally, two unlabeled urinals without lids were observed hanging over the commode in a shared bathroom between two rooms. Furthermore, brown matter was noted on the commode in another shared bathroom. These observations indicate lapses in infection control protocols, which were confirmed by a Geriatric Nursing Assistant during the survey. Interviews with facility staff revealed further insights into the deficiencies. The Infection Prevention Nurse stated that urinals should not be left in the bathroom but should be placed in a plastic bag and stored in residents' drawers, and they must be labeled. The Environmental Service Manager mentioned that rounds are conducted regularly to ensure cleanliness, with housekeepers working in shifts to maintain hygiene. The Director of Nursing confirmed that nursing staff have access to cleaning supplies if needed. Despite these protocols, the observed deficiencies suggest a failure in adhering to established infection control practices.
Deficiencies in Controlled Medication Management
Penalty
Summary
The facility failed to adhere to professional standards of practice regarding the management of controlled medications. During a random narcotic reconciliation observation, it was found that controlled medications were not signed off by the LPN upon removal from the narcotic drawer for three residents. Specifically, discrepancies were noted in the narcotic control forms for Lorazepam and Pregabalin for one resident, and Lorazepam for another, where the number of pills in the blister packs did not match the recorded count. Additionally, Oxycodone IR for a third resident was not signed off in the narcotic book after administration. Further issues were identified with the safety and integrity of narcotic medications. A blister pack for a resident contained a Tramadol pill sealed with tape, and another resident's Acetaminophen Codeine blister pack had damaged pills that should have been wasted. The facility also failed to ensure that two nurses signed the narcotic sheet during change of shift to verify the narcotic count was complete. Several instances were noted where only one nurse signature was present on the shift count sheets, indicating a lack of proper verification. Interviews with staff revealed a lack of adherence to the facility's policy that requires narcotics to be signed off immediately when removed from the narcotic drawer. The DON acknowledged the issues and stated that the facility's policy was not followed. The nurse manager admitted to missing the signature part during audits, and the DON confirmed that the practice of not signing the narcotic logbook was unacceptable.
Inadequate Kitchen Staffing
Penalty
Summary
The facility failed to ensure adequate staffing levels in the kitchen, affecting all residents. On multiple occasions, the surveyor observed insufficient staffing, including instances where only one cook and one or two culinary aides were present after 5 PM. Staff #15, who was originally in maintenance, was observed working in the kitchen, indicating a lack of specialized kitchen staff. The food committee minutes also documented various kitchen concerns due to the lack of staff, such as the inability to call the kitchen, lack of soup or chili, and no time to make desserts or cakes. The surveyor's review of the kitchen staffing schedules from 3/1/24 to 4/4/24 revealed consistent understaffing, with many shifts having fewer than the required 1 cook and 3 culinary aides. The facility assessment failed to identify the necessary food and nutrition services staff needed. The facility Administrator and the Regional Director of Operations acknowledged the surveyor's concerns, confirming the deficiency in the facility's assessment of kitchen staffing needs.
Multiple Deficiencies in Food Service Safety and Sanitation
Penalty
Summary
The facility failed to ensure the monitoring and oversight of food temperatures in accordance with professional standards for food service safety. During the surveyor's initial tour of the kitchen, it was observed that food temperature logs were incomplete on multiple dates. Specific instances included missing temperature logs for lunch and dinner meals on several dates, and the surveyor's temperature testing of food trays revealed that the main entree was served at temperatures below the required standards. Interviews with kitchen staff confirmed that food temperatures had not been taken, and food committee minutes documented recurring complaints about cold food from residents. The facility also failed to follow sanitary practices in accordance with professional standards for food service safety. Observations included a cutting board resting against a kitchen rack wheel close to the floor, beverage device nozzles resting on the kitchen floor, and wet nesting of trays. Interviews with kitchen staff confirmed these observations, and immediate actions were taken to address the concerns. However, these practices were not in line with maintaining a sanitary kitchen environment. Additionally, the facility did not ensure that food was stored properly, as evidenced by a container of mayonnaise-based salad with a cracked lid in the walk-in refrigerator. The dishwasher also failed to reach adequate temperatures according to the manufacturer's guidelines, with documented instances of the machine not meeting the required minimum wash and rinse temperatures. Lastly, the facility's food supply order was inadequate, as evidenced by a resident's complaint about the lack of milk and the observation of a limited milk supply in the kitchen. Interviews with kitchen staff confirmed issues with food ordering and supply management.
Failure to Employ Full-Time Social Worker
Penalty
Summary
The facility failed to employ a qualified social worker on a full-time basis, which was identified during a recertification survey. A review of the facility's list of key personnel on 4/02/24 revealed the absence of a social worker. On 4/03/24, the Activities Director confirmed that she had been providing social work services since November 2023, despite not being a qualified social worker. The Nursing Home Administrator (NHA) acknowledged in interviews on 4/03/24 and 4/12/24 that the facility, which has a capacity of more than 120 beds, did not employ a full-time social worker since the previous one left at the end of January 2024.
Failure to Conduct Quarterly QAPI Meetings
Penalty
Summary
The facility failed to meet at least quarterly to conduct required Quality Assurance and Performance Improvement (QAPI) activities. This was identified during a recertification survey. The review of QAPI sign-in sheets from November 2023 through March 2024 revealed that the facility did not hold a QAPI meeting in November and December 2023 or in January 2024. Instead, the facility provided sign-in sheets for clinical standard weekly meetings held from November 16, 2023, through January 26, 2024, which were not QAPI meetings. The Nursing Home Administrator (NHA) acknowledged in an interview that the facility did not hold QAPI meetings during this period and had an Ad Hoc QAPI meeting on February 26, 2024, to address the issue.
Failure to Include Dietary Staffing in Facility Assessment
Penalty
Summary
The facility failed to include dietary staffing in their facility-wide assessment, which is necessary to determine the resources required for competent resident care. This deficiency was identified when a surveyor observed a staff member, whose job title was maintenance, working in the kitchen as a culinary aide. The staff member reported that they had been performing various roles within the facility, including maintenance and social work, and had been working in the kitchen for the past two weeks. The staff member also indicated that on Mondays, the kitchen was staffed only by themselves and the cook. Further review of food committee minutes revealed multiple concerns related to kitchen operations, including a lack of staff leading to issues such as the inability to call the kitchen, lack of soup or chili, and insufficient time to prepare desserts or cakes. During an interview, the Dietary District Manager admitted to being unfamiliar with the facility assessment. The surveyor reviewed the facility assessment, last updated on 11/30/23, and found that it did not identify any food and nutrition services staff needed. Additionally, no food service staff were included in the assessment tool outlining persons involved in completing the assessment. The facility Administrator confirmed the omission of food and nutrition services staffing in the assessment. After the surveyor's intervention, the Administrator updated the facility assessment to include the necessary food and nutrition services staffing.
Failure to Revise Care Plans and Hold Timely Care Plan Meetings
Penalty
Summary
The facility failed to revise and update comprehensive care plans within seven days after completing comprehensive assessments and did not hold care plan meetings with residents and/or their representatives. This deficiency was identified for five residents during the recertification survey. For instance, Resident #88's care plan inaccurately included interventions for nicotine use despite the resident having quit smoking a year ago and having no active orders for nicotine products. The Nursing Home Administrator confirmed that the care plan had not been revised and was inaccurate. Resident #87's medical record revealed that a care plan meeting was not documented within seven days of the quarterly MDS assessment. The unit director confirmed the absence of documentation for a care plan meeting since the last quarterly assessment. Similarly, Resident #61's medical record did not show evidence of a care plan meeting after the quarterly MDS assessment, and the facility provided a document to a cognitively impaired individual without proper documentation of the resident's or responsible party's participation. Resident #75's care plan meetings were documented 15 and 19 days after the comprehensive assessments, respectively, which exceeded the required seven-day timeframe. Additionally, Resident #110's medical record showed that care plan meetings were held 17 days after the comprehensive assessment, and there was no documentation that the resident's representative was notified or attended the meetings. The Director of Nursing confirmed these concerns during an interview with the surveyor.
Failure to Address Medical Orders, Timely Care, and Follow-Up Appointments
Penalty
Summary
The facility failed to have a process in place to address and review medical orders pending provider signature, provide timely care for residents who experienced a change in condition, and timely arrange for a resident to go for their 2-weeks follow-up post-op visit. For Resident #46, the facility did not have a process to ensure that duplicate medication orders pending provider signature would not result in the resident receiving a duplicate dose. Staff interviews revealed that there was no system in place to prevent this, relying instead on nurse-to-nurse verbal reports, which could lead to errors if not communicated properly. This was confirmed by multiple staff members, including the Acting Unit Manager and the Infection Control Preventionist and Educator, who acknowledged the concern when it was brought to their attention by the surveyor. Resident #109 experienced a decline in condition, including difficulty chewing and sitting up unassisted, which was documented on 1/31/24. Despite abnormal lab results indicating kidney issues, there was confusion and lack of communication among staff regarding the administration of IV fluids. The CRNP was unaware that the resident had been placed on IV fluids and there was no documentation of the decision-making process. The resident was eventually transferred to the hospital on 2/3/24, but the delay in timely intervention and lack of clear communication among the interdisciplinary team contributed to the deficiency. Resident #110 had a change in condition on 2/22/24, including lethargy, slow response, and elevated pulse rate, but did not receive any interventions until being transferred to the hospital on 2/23/24. The medical record lacked documentation of any interventions for the resident's change in condition on 2/22/24. Staff interviews revealed discrepancies in the documentation, with the attending NP insisting he did not see the resident on 2/22/24 despite progress notes indicating otherwise. The Director of Nursing and other staff members acknowledged the concern when it was brought to their attention by the surveyor. Additionally, Resident #107 was unable to have a timely 2-weeks post-op follow-up visit due to scheduling issues, which were not communicated to the surgeon or the resident's family, nor documented in the medical records.
Delayed Documentation of Medical Records
Penalty
Summary
The physician/Certified Registered Nurse Practitioner (CRNP) progress notes were not written, signed, and timely present in the resident medical records. This deficiency was evident for two residents reviewed during the survey. For Resident #46, multiple instances were noted where psychotherapy visit notes, x-ray reports, and other consults were not uploaded to the medical record within the facility's expected timeframe of 72 hours. For example, a psychiatric note dated 3/15/24 was not uploaded until 3/21/24, and several other notes had similar delays. During an interview, the CRNP admitted that the documentation for weekly visits had not been uploaded to the medical record, which was confirmed by the Director of Nursing (DON) who acknowledged the provider was not in compliance with the facility's documentation policy. For Resident #109, the CRNP's Acute Visit note dated 2/1/24 was not signed until 2/4/24, by which time the resident had already been transferred to a hospital on 2/3/24. This delay meant that the CRNP's note was not available in the resident's chart for review during the critical period before the transfer. A meeting with the DON, Divisional VP of clinical services, Division VP of Clinical Assessment and Reimbursement, and the CRNP confirmed that the late note would not have been in the resident's chart for review on the necessary dates, further highlighting the issue of delayed documentation.
Failure to Treat Resident with Respect and Dignity
Penalty
Summary
The facility failed to treat residents with respect and dignity, as evidenced by an incident involving a Geriatric Nursing Assistant (GNA) and a resident. The incident occurred when the GNA dragged the resident backwards on a shower chair through the hallway from the resident's room to the shower room and back. The resident reported that the GNA could not pull them forward because their feet were dragging on the floor. The GNA confirmed that the footrest on the shower chair was broken and did not stay in place, leading to the backward dragging of the resident.
Failure to Notify Representative and Physician of Diet and Medication Changes
Penalty
Summary
Facility staff failed to notify a resident's representative party and physician when the resident had a change in diet order and a new prescribed medication. This was evident for one resident who had their diet order changed from regular to dysphagia puree and was prescribed cough medication without proper documentation or notification to the relevant parties. The resident's loved one was unaware of the diet change and the new medication until the resident was transferred to the hospital with pneumonia. Interviews with staff revealed that the speech therapist changed the diet order based on an evaluation but did not ensure the change was communicated to the nursing, dietitian, and dietary manager. Additionally, the Licensed Practical Nurse stated that all changes should be reported and documented, which did not occur in this case. The Nurse Practitioner who placed the order for the cough medication did not have a note regarding the resident's cough, and the Director of Nursing acknowledged that the process for documenting and communicating changes was not followed correctly.
Failure to Inform and Assist Residents with Advance Directives
Penalty
Summary
The facility failed to inform residents of their right to establish an advance directive and provide assistance if the resident wished to execute one or more directives. This deficiency was identified for three residents during a review of their medical records, which revealed no documentation indicating that the facility staff provided advance directive information or assistance. Interviews with facility staff, including a registered nurse, the nursing home administrator, a regional social worker, and the admission director, confirmed that there was a lack of clarity and responsibility regarding who should provide this information to residents. The registered nurse stated that providers and social workers were responsible for assisting residents with advance directives, while the regional social worker indicated that the admission department managed new residents' advance directives. However, the admission director stated that she did not handle clinical tasks, including advance directives. The nursing home administrator validated the surveyor's concerns about the lack of opportunity for residents to formulate an advance directive, highlighting a systemic issue in the facility's process for managing advance directives.
Failure to Notify Residents of Bed Hold Payment Policy
Penalty
Summary
The facility failed to notify residents or their representatives in writing of the reserve bed payment policy upon transfer to an acute care facility. This deficiency was identified for three residents during the recertification/complaint survey. Specifically, the medical records of Residents #72, #88, and #108 showed that while the bed hold policy was mentioned in the acute transfer letters, the daily payment amount for holding the bed was not included. This omission was consistent across all reviewed cases of hospitalization for these residents. A review of the facility's bed hold policy indicated that the Admissions Director or Designee is responsible for notifying the resident or responsible party about the bed hold costs within 24 hours of the resident leaving the facility. However, interviews with the Director of Nursing confirmed that the daily amount for the bed hold was not provided in the notifications. This lack of information about the cost associated with holding a bed during hospitalization or therapeutic leave led to the identified deficiency.
Incomplete Care Plan for Pressure Ulcers
Penalty
Summary
The facility failed to ensure care plans were comprehensive for a resident with pressure ulcers. Specifically, the care plan for a resident with a sacral wound did not include this wound, despite having documented orders for daily dressing changes. The care plan only listed wounds on the resident's left heel and left buttock. This deficiency was confirmed through a record review and an interview with a registered nurse, who acknowledged the omission. The issue was brought to the attention of the Nursing Home Administrator by the surveyor.
Improper Use of Hoyer Lift During Resident Transfer
Penalty
Summary
The facility failed to ensure that resident care was provided in a safe manner, as evidenced by an incident involving the improper use of a Hoyer lift. During a transfer from the bed to a shower chair, a Geriatric Nursing Assistant (GNA) used the Hoyer lift without the assistance of a second staff member, which is required for safe operation. The resident reported being positioned at a 45-degree angle on the shower chair, with their buttocks hanging half off the chair, necessitating the resident to hold themselves to avoid sliding out. This incident was reported to the Office of Health Care Quality and was confirmed through interviews with the resident and other staff members, including the GNA involved and another GNA who corroborated the resident's account. The GNA involved in the incident admitted to using the Hoyer lift alone due to a lack of available staff, citing chronic short-staffing issues. The resident had reported the rough handling and improper use of the lift to another GNA, who confirmed that Hoyer lift transfers always require two staff members. The Nursing Home Administrator acknowledged the incident and provided a revised final report, which included the resident's allegations and the GNA's admission. The facility's investigation file contained witness statements that supported the resident's account of the incident.
Failure to Monitor and Respond to Weight Changes
Penalty
Summary
The facility failed to have a system to monitor and respond to changes in residents' weights and notify the physician when weight loss was identified. This was evident for one resident reviewed for nutrition during the survey. The resident's body weight was documented as 334 pounds on 3/22/24 and 324 pounds on 3/26/24, showing a ten-pound difference within four days. However, there was no documentation in the resident's medical records regarding this weight loss. Interviews with a Registered Nurse and the Director of Nursing revealed that nurses should verify residents' body weight, follow up on differences, and report significant changes to providers. The Director of Nursing confirmed that a more than five-pound difference would be concerning and should be reported and documented, which did not occur in this case.
Failure to Evaluate and Manage Resident's Pain
Penalty
Summary
The facility failed to evaluate and manage the pain of a resident effectively. Resident #354 reported experiencing pain in both legs and stated that the prescribed Morphine was not alleviating the pain. Despite the resident's complaints and high pain scores, there was no evidence that the facility staff evaluated the resident's pain or adjusted the pain management plan accordingly. The resident's Medication Administration Record (MAR) showed multiple instances where the pain score exceeded the prescribed parameters, yet there was no documentation of the nursing staff contacting the provider to discuss the resident's pain management needs. Interviews with the facility's RN and Nurse Practitioner confirmed that the protocol required nurses to assess pain before administering medication and to contact the provider if the pain score exceeded the prescribed parameters. However, this protocol was not followed in the case of Resident #354. The Nursing Home Administrator validated these concerns when they were shared by the surveyor, indicating a lapse in the facility's pain management practices for this resident.
Failure to Verify GNA Competency
Penalty
Summary
The facility failed to ensure that Geriatric Nursing Assistants (GNAs) were competent with their skill sets, as evidenced by a review of employee files and interviews. Specifically, three out of five randomly selected GNA employee files (GNA #39, #40, and #41) lacked records to support their competency. The surveyor found that the orientation forms for these GNAs did not include signatures from those who provided education or verified their skills, nor did they have documented dates. Staff #4 confirmed that the facility did not have supportive evidence to verify the competency skills of these agency staff members.
Failure to Follow Medication Parameters
Penalty
Summary
The facility failed to follow the recommended parameters prescribed by the physician when administering blood pressure and pain medications for Resident #28. Specifically, the medical records revealed that the resident was prescribed Metoprolol Tartrate with instructions to hold the medication if the systolic blood pressure (SBP) was less than 110 or the heart rate (HR) was less than 60. However, the Medication Administration Records (MAR) from January through March 2023 showed that the blood pressure readings were not documented prior to the administration of the medication, as required by the physician's order. Additionally, the resident was prescribed Oxycodone for pain levels 5-10 and Acetaminophen for pain levels 1-3, but the MAR indicated that these medications were administered outside of the prescribed pain levels on multiple occasions during the same period. Interviews with staff members, including a Registered Nurse (RN), a unit manager, and a Nurse Practitioner (NP), confirmed that the facility's protocol required checking and documenting blood pressure before administering BP medications and assessing pain levels before administering pain medications. The staff acknowledged that medications should not be given outside the recommended parameters. The Director of Nursing (DON) was also made aware of these concerns during the discussion with the NP, highlighting the facility's failure to adhere to the prescribed medication parameters for Resident #28.
Lack of Qualified Dietetic Service Supervisor in Kitchen
Penalty
Summary
The facility failed to ensure that the overall supervisory responsibilities for the kitchen were assigned to a qualified dietetic service supervisor. During the initial tour of the kitchen, the surveyor interviewed the Culinary Director, who admitted they were not a Certified Dietary Manager. The Culinary Director also mentioned that the Dietary District Manager, who oversees multiple facilities, visits the building two to three times per week. Further interviews revealed that the Registered Dietician, who works 30 hours a week, was not in charge of the kitchen and was primarily hired for clinical staff duties. The facility assessment identified the need for one full-time dietician but did not specify the need for any food and nutrition services staff. The surveyor's review of the facility assessment and interviews with various staff members confirmed that the kitchen lacked proper supervision by a qualified dietetic service supervisor. The Registered Dietician confirmed that they were not responsible for supervising the kitchen and that documented kitchen consultations had not occurred since December 2023. The facility Administrator also confirmed that the Registered Dietician was not in charge of the kitchen. This lack of proper supervision and oversight in the kitchen led to the deficiency noted in the report.
Failure to Thoroughly Investigate Allegations of Abuse
Penalty
Summary
Facility staff failed to ensure that all allegations of abuse were thoroughly investigated. This was evident for one resident who reported being tossed to bed by two staff members. The facility's investigation included statements from two Geriatric Nurse Aides and one Licensed Practical Nurse, but these staff members were not listed on the assignment sheet for the night in question. Additionally, the Nursing Home Administrator could not verify the exact date of the incident, and there was no documentation to support the investigation of the reported date or to identify the perpetrators. There was also no statement from the resident involved.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to provide dental services to meet the needs of Resident #17, who was observed to have only bottom dentures and no natural upper teeth. The resident reported that their upper dentures had been lost a few months ago and had not been replaced. Despite a care plan meeting held the previous week where the resident was informed that a dentist would come to the facility to take impressions, no follow-up had occurred. A review of the resident's medical record revealed a care plan problem for poor-fitting dentures, but no dental care notes or documentation related to dental services were found. The facility was unable to provide the requested documentation regarding the resident's dental care. Interviews with the Director of Nursing (DON), Nursing Home Administrator (NHA), Unit Manager, and Licensed Practical Nurses (LPNs) revealed that the facility was unaware of the dentist's recommendations made in September or October 2023. The Unit Manager stated that the resident's family was supposed to pay for the missing dentures and handle the situation, but no grievance form or documentation was found in the medical record. The NHA acknowledged that the resident did not receive timely care for their dental needs. The facility's failure to ensure the resident's dental needs were met led to the deficiency identified by the surveyors.
Failure to Document Certifications of Incapacity and Guardianship Disputes
Penalty
Summary
The facility failed to adequately document certifications of incapacity and ensure the accuracy of the Maryland Medical Orders for Life-Sustaining Treatment (MOLST) form for Resident #15. The surveyor found that the MOLST form indicated the resident had a guardian, but no documentation of a guardian was present in the medical record. Additionally, the Certification of Incapacity forms were incomplete, missing critical information such as the identification of the patient, the certifying practitioner's credentials, and the reason for incapacity. The second Certification of Incapacity form also lacked necessary details, including the certifying practitioner's credentials and a diagnosis or reason for incapacity. These deficiencies were acknowledged by the facility staff upon review by the surveyor. The facility also failed to document pertinent information regarding surrogacy and guardianship disputes in the medical record for Resident #101. The resident's medical record contained conflicting information about the resident's healthcare proxy, with different documents indicating either the mother or the father as the representative. Additionally, a notice about ongoing guardianship proceedings was found taped in the resident's closed medical record, but no formal documentation of the dispute or protective orders was included in the medical record. The facility Administrator confirmed the existence of the dispute but acknowledged that it was not documented in the resident's record.
Failure to Post Survey Results in Accessible Locations
Penalty
Summary
The facility staff failed to ensure the results from the last annual survey were posted in a place readily accessible to residents and visitors. During an observation, a surveyor found a white binder labeled Annual Survey Results Book #2 on a shelf beside the receptionist desk in the front lobby, which did not include the results from the last annual survey conducted by the State Agency. A tour of all common areas accessible to residents and visitors revealed no additional survey results, despite a sign indicating their availability in specific locations. The survey results were not visible and accessible in the indicated locations, and the binders found in the locked Alzheimer's Care Unit (ACU) nurses' station did not contain the most recent survey results and were not readily accessible to residents without having to ask for them. In an interview, the receptionist indicated that there might be another binder in the administrator's office. The Administrator confirmed that the survey results book in the lobby did not contain the results of the last survey and that the binders in the ACU nurses' station contained very old surveys. The Administrator acknowledged that the survey results were not accessible to the ACU residents without having to ask for them and that the survey results were not posted in the locations indicated by the sign on the ACU bulletin board.
Latest citations in Maryland
The facility did not ensure that its Infection Preventionist (IP) met required qualifications for managing the Infection Prevention and Control Program. The DON reported serving as the IP but acknowledged lacking the specialized infection control training required for the role, and confirmed that no other staff member was currently qualified. Records showed that the previously qualified IP left several months earlier, and the Administrator and DON confirmed they were still seeking a replacement, leaving the infection control program without a properly trained leader.
Staff failed to consistently secure medications and medical supplies across three units, including an oxygen tank left on the floor behind a resident’s bed without a supporting device, a treatment cart with Collagenase Santyl cream left on top while two residents in power wheelchairs passed by, an unattended and unlocked treatment cart at a nursing station, and another treatment cart with Diclofenac gel and dressings left on top, indicating repeated lapses in maintaining locked and secure storage for drugs, biologicals, and related supplies.
The facility failed to provide sufficient dietitian coverage and timely nutritional assessments for several residents with significant dietary needs. A resident admitted for diabetic management with a high A1C was placed on a regular diet instead of the recommended carb-controlled diet and had only one weight taken in the first two weeks, with no dietitian review of the record. Another resident with prior significant weight loss had no documented dietitian follow-up despite continued weight loss, and a resident admitted with severe protein-calorie malnutrition experienced further significant weight loss without any dietitian assessment. The dietitian reported working limited hours and prioritizing certain high-risk cases, resulting in delayed or missed evaluations for new admissions and residents with ongoing nutritional concerns.
The facility failed to maintain adequate linen and incontinence supplies and did not keep resident care areas in good repair, resulting in delays and alterations in incontinence care and substandard environmental conditions. Staff reported that towels and washcloths were used instead of wipes and then discarded due to heavy soiling, and that linen deliveries to units were late, leaving residents waiting for care. Observations showed very limited numbers of clean washcloths and other linens on units and in the laundry, with no stock of disposable wipes or backup washcloth supply despite repeated reports to housekeeping. Additional observations revealed recliner chairs blocking a dining-area handwashing sink and kitchenette, multiple resident and shared bathrooms with unfinished spackle, chipped paint, musty odors, black substances near showers, missing threshold molding, exposed cracks and nails, and eroded, rusted baseboard heaters. Hallway handrails on both units were worn, chipped, and splintered, and a shower room contained fecal odors, dried brown stains on the toilet, and deteriorated fixtures, all contributing to a failure to provide a safe, clean, and homelike environment.
Facility staff did not thoroughly investigate two separate abuse allegations involving a resident and an injury of unknown origin involving another resident. In both cases, investigations focused on the directly affected resident and included staff interviews, but there were no interviews of other residents on the unit or documented assessments of those residents for signs of abuse or injuries of unknown origin, including residents unable to communicate due to cognitive status.
Two residents who were dependent on staff for oral care, including one with a tracheostomy, were observed with thick, white or milky substances coating their mouths and teeth, indicating inadequate oral hygiene. One resident communicated that staff did not brush their teeth and that staff "need to." In another case, despite oral care supplies being present in the room, the resident’s mouth and teeth remained unclean on multiple observations, with a thick milky substance caking the teeth and stringing between them when the resident tried to open their mouth. These findings showed that staff did not consistently provide oral care to residents who relied on them for this ADL.
Staff failed to maintain complete and accurate medical records for multiple residents, including missing and inconsistent documentation of wound care, delayed pain assessment after discovery of an injury of unknown origin in a cognitively impaired resident, and inaccurate recording of a PPD test result that was documented as negative despite no evidence the injection was administered and no supporting nurse’s note. Residents reported not receiving certain treatments, while MAR entries either lacked signatures for completion or contained conflicting information about whether care was provided.
Surveyors found that the facility failed to consistently implement and communicate correct transmission-based precautions and PPE use. One resident with a Foley catheter related to wounds had no precaution signage posted, while another resident in a double room had a contact precautions sign at the door, yet the NP entered without PPE and the GNA provided high-contact care wearing only gloves. Staff in that room stated the resident was not on contact precautions and later reversed the sign to show no PPE requirement. Therapy staff reported they rely solely on posted signs to determine PPE, and surveyors identified broader issues with inaccurate signage and staff awareness of which residents required contact precautions.
Surveyors found that MDS assessments were inaccurately coded for two residents. In one case, a resident sustained a femoral neck fracture after a fall, but the subsequent significant change MDS did not code the fall as a major injury and failed to capture prn Tylenol use documented on the MAR within the look-back period. In the other case, a quarterly MDS indicated opioid use for a resident, but the MAR for the same period showed no prescribed opioid, indicating incorrect coding of high-risk drug classes.
A resident who had recently been admitted and experienced a fall received multiple doses of the narcotic analgesic Tramadol, but the facility failed to accurately document all administered doses on the Medication Administration Record (MAR). Review showed only one Tramadol dose recorded on the MAR, while the Controlled Drug Receipt/Record/Disposition Form on the med cart reflected three doses given over two days. In interview, the DON stated staff are expected to document narcotic administration on the MAR and confirmed that two administered doses were not recorded there, resulting in an incomplete and inaccurate medical record.
Unqualified Infection Preventionist Overseeing Infection Control Program
Penalty
Summary
The facility failed to ensure that its designated Infection Preventionist (IP) met the mandatory qualifications for overseeing the Infection Prevention and Control Program. During an interview on 3/24/26 at 10:00 AM, the DON confirmed that she/he was serving as the facility’s IP but had not completed the specialized training in infection control required for the position. The DON further stated that no other staff member currently met the qualifications to serve as IP. Record review showed that the previously qualified IP left the facility in October 2025, and as of the survey date, the position remained unfilled by a qualified individual. At 1:30 PM on the same day, the Administrator and DON confirmed they were still in the process of finding a qualified IP for the facility, leaving the Infection Prevention and Control Program without a properly trained and qualified leader. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency.
Unsecured Medications, Treatment Carts, and Oxygen Equipment
Penalty
Summary
Facility staff failed to ensure that drugs, biologicals, and related medical supplies were securely stored and properly maintained on multiple units. On one unit, an oxygen tank assigned to a resident was observed sitting on the floor behind the resident’s bed without any supporting device. On another unit, a treatment cart was observed with a tube of Collagenase Santyl cream labeled for a specific resident left on top of the cart, while residents in power wheelchairs passed by and staff were present at the nursing station. These observations showed that medications and oxygen equipment were not consistently secured as required. Further observations on additional units revealed an unattended and unlocked treatment cart at a nursing station, and on a separate occasion, a treatment cart with Diclofenac gel labeled for a resident left on top along with multiple packs of dressings. These incidents occurred across three units and on more than one date, demonstrating repeated failures to keep medications and treatment supplies in locked compartments or otherwise secured from unauthorized access.
Insufficient Dietitian Coverage and Delayed Nutritional Assessments
Penalty
Summary
The deficiency involves the facility’s failure to employ sufficient food and nutrition staff, including adequate dietitian coverage, to ensure timely assessment and appropriate diets for residents with significant nutritional and diabetic needs. A resident admitted over two weeks earlier with multiple comorbidities and an A1C of 11.5% had a hospital discharge recommendation for a carbohydrate-controlled diet, but was placed on a regular diet at admission with no acknowledgment of the recommended diet until one week later, when the resident requested larger portions. As of the survey date, the dietitian had not yet seen or reviewed this resident’s medical record, and the resident reported not having seen a dietitian and being very frustrated with the meals. During the first two weeks after admission, only one weight was obtained for this resident, despite physician notes stating the resident’s weight was “stable.” Further review of other residents showed additional failures in timely dietitian assessment and follow-up. One resident, readmitted in January and previously seen by the dietitian in September for a 6.4 lb weight loss over 30 days, had no documented follow-up despite continued weight loss totaling 22 lbs since the last dietitian review. Another resident admitted at the end of February with severe protein-calorie malnutrition had not been seen by the dietitian after about a month in the facility, despite a documented 14 lb (7%) weight loss over two weeks. The dietitian reported working only 12 hours per week at the facility and stated that she must prioritize which residents to see, focusing first on residents with tube feedings and those identified in risk meetings, resulting in delayed or absent assessments for new admissions and residents with ongoing weight loss and malnutrition diagnoses.
Linen Shortages and Poor Environmental Maintenance Compromise Resident Care and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to maintain an adequate supply of clean linens and appropriate incontinence wipes, resulting in delays and alterations in residents’ incontinence care, as well as the use of towels and washcloths in place of disposable wipes. During the initial tour, the surveyor observed that the linen supply on one nursing unit hallway was low. Complaint reviews included concerns about delays in incontinence care and bed linens not being changed regularly, with residents left without clean bedding. A complainant reported that there was not enough clean linen available for residents. Staff interviews confirmed that towels, sheets, and washcloths were being used to wipe residents for incontinence care due to the absence of wipes, and that many of these linens were being thrown away when soiled. Staff also reported a shortage of linen, that linen deliveries to the units were late, and that residents who preferred to get up before breakfast had to wait for care when linen was delayed. Further observations showed that the clean supply room contained no disposable wipes or cloths for incontinence care, and a resident reported that staff did not use wipes, that the resident had to purchase their own, and that heavily soiled towels or washcloths were discarded. A tour of all nursing unit linen carts and closets revealed only six clean washcloths and limited supplies of towels, gowns, and bed linens. In the laundry room, only three washcloths were present, and the laundry assistant stated that there were only three washcloths available for each nursing unit that morning, that the facility was short on linen supply, and that these concerns had been repeatedly reported to the Director of Housekeeping over the preceding month and again that morning. The laundry assistant confirmed there was no additional laundry in process. The DON stated that wipe squares should be used for incontinence care, but no such wipes were found in the clean medical supply room, and no backup supply of washcloths was present in the emergency linen supply. The Director of Housekeeping confirmed there was no backup supply of washcloths. The deficiency also includes environmental and maintenance issues affecting resident bathrooms, handrails, and common areas. In the main dining area, a recliner chair was observed positioned directly in front of the handwashing sink, and two recliner chairs were stored in front of the nutrition area kitchenette. Multiple resident bathrooms and shared bathrooms were repeatedly observed over several days with unfinished spackle on walls that needed resurfacing and painting, chipped paint around sinks, uneven boards nailed to walls under sinks that appeared to partially cover holes, musty odors, black substances between shower bases and walls, missing threshold transition molding exposing cracks, missing tiles, and a nail, as well as eroded and chipped paint on baseboard heaters with exposed dark brown metal and rust-like material. Hallway handrails on both nursing units were observed to be worn, with chips, splintering, holes, and areas where the wood finish had worn off. A shower room was observed with a foul fecal odor, dried brown stains on the back of the toilet seat and in the toilet bowl, and a baseboard heater with eroded, chipped paint and rust-like material, along with chipped paint on the handrail. These conditions were acknowledged by the Director of Maintenance and other leadership, and some areas were noted to be in the process of renovation, but the observed deficiencies remained present during the survey period. Overall, the facility did not maintain a safe, clean, comfortable, and homelike environment in good repair across both nursing units and the dining area. The lack of adequate linen and incontinence supplies, combined with the poor condition of resident bathrooms, handrails, and certain common areas, constituted the basis for the cited deficiency. The observations and staff and resident reports consistently described shortages of essential hygiene supplies, delayed care related to linen availability, and multiple unresolved environmental and maintenance issues in resident care areas and shared spaces.
Failure to Thoroughly Investigate Abuse Allegations and Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate allegations of potential abuse involving one resident and an injury of unknown origin involving another resident. For one resident, there were two separate allegations of abuse occurring on different days in early February. The facility’s investigation packets included interviews with staff who cared for or were scheduled to work with this resident on the days of the alleged incidents, and the investigations focused solely on this resident. However, there were no interviews conducted with other residents on the unit to inquire about abusive or neglectful treatment by the staff who were working during the times of the allegations. The surveyors noted that, although the allegations were not validated, there was no documentation that other residents were interviewed, if able, or assessed for signs or symptoms of injury. In a separate incident, another resident was identified on March 4 with a new bruise on the right eye, documented as a change in condition at 4:09 AM. This resident had a BIMS score of 99, indicating the resident was unable to complete an interview and therefore could not report how the injury occurred. The facility’s investigation identified a potential cause of the injury but did not reach a definitive resolution. Additionally, there were no interviews of other residents on the unit regarding possible abuse, nor were there documented assessments of other residents for injuries of unknown origin, particularly for those unable to speak for themselves, as in this resident’s case.
Failure to Provide Oral Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide oral care to residents who were dependent on staff for activities of daily living, specifically oral hygiene. One resident with a tracheostomy was observed with a thick, sticky white substance in the mouth and was noted to intermittently chew on nearby bedding. This resident made good eye contact and, when asked if staff brushed their teeth, shook their head no and mouthed that staff “need to.” According to the resident’s Minimum Data Set (MDS) dated 2/11/26, the resident was dependent on staff for oral care. Another resident, also dependent on staff for oral care per the 3/11/26 MDS, was observed sitting propped up in bed and able to respond with smiles. During the initial observation, the inside of this resident’s lips and upper and lower teeth had a thick, clear, white milky substance visible when the resident tried to open their mouth to smile. Oral care supplies were present in the nightstand, but the resident’s mouth and teeth were not clean. On a subsequent observation with the DON, NHA, and Corporate VP of clinical services, the same resident again had a thick, clear, milky substance between the lips and caking the teeth, which would string between the teeth when the resident attempted to open their mouth, demonstrating a lack of consistent oral care for residents dependent on staff for this ADL.
Incomplete and Inaccurate Medical Record Documentation for Treatments and Assessments
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records and documentation for multiple residents. For one resident with wound care needs, review of the MAR showed that wound care and related treatments were signed as completed on the dates initially reported, despite the resident’s ongoing complaints that wound dressings were not being changed. When additional dates were reviewed, there were missing staff signatures for wound care on two specific dates, as well as three instances where application of A&D ointment to the resident’s feet was not signed off out of 24 days reviewed. Another resident with severe cognitive impairment, as evidenced by a BIMS score of 00, was found to have an injury of unknown origin (a bruise on the left hand). Documentation showed that a change in condition was initiated late in the morning, but a formal pain evaluation was not initiated and completed until that night, and the resident was unable to explain how the injury occurred or verbalize pain using a standard pain scale. For a third resident, documentation related to the admission PPD test was inconsistent and incomplete. The MAR contained an entry indicating “9” for the administration date, meaning “see nurse’s note,” but there was no corresponding nurse’s note. Despite the absence of a signed administration of the PPD injection, staff documented the PPD result as “negative” on the scheduled read date. The resident reported never receiving the PPD injection, and the DON confirmed that the facility had been out of PPD solution at the time, so the test would not have been administered. These findings demonstrate failures in accurate documentation of treatments and assessments, including wound care, pain assessment, and TB screening, as well as missing or incomplete supporting notes in the medical record.
Failure to Implement and Communicate Correct Transmission-Based Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to inconsistent and incorrect implementation of transmission-based precautions and PPE use. During a complaint investigation focused on residents on transmission-based precautions, one resident with a visible Foley catheter was observed in the room with physical therapy, but there were no signs posted indicating any need for PPE, despite the resident being a new admission with a Foley catheter placed related to wounds. In another double-occupancy room, a contact precautions sign was posted at the doorway, but the nurse practitioner was in the room on a personal phone with no PPE, and the assigned GNA was repositioning the resident in bed while wearing only gloves. When questioned, the NP, RN, and GNA all stated that the resident in the room was not on contact precautions, and the GNA reported that signs were hanging at all doors and that this particular resident’s sign was “just wrong.” The surveyor observed the GNA later return to the room and turn the sign around to indicate no PPE requirement. Subsequent interviews revealed that therapy staff relied on posted signage to determine PPE use and that if the sign was wrong, the PPE used would be wrong. Overall, surveyors found problems with signage accuracy and staff awareness of which residents required contact precautions, as well as observed failures to follow appropriate PPE use for residents who should have been on contact precautions.
Inaccurate MDS Coding for Falls, Pain Management, and High-Risk Medications
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for two residents reviewed during a complaint survey. For one resident, a facility-reported incident showed that the resident was found seated on the floor beside the bed and was diagnosed with a non-displaced femoral neck impaction fracture of the left hip following an x-ray. Despite this fall with a major injury, the subsequent significant change MDS dated 11/4/25 did not code the fall with major injury in Section J1900C. Review of the resident’s Medication Administration Records for October and November 2025 showed administration of Tylenol on 10/31/25 at 9:30 PM, which fell within the 5-day look-back period for the MDS, but Section J0100 (prn pain) of the same significant change MDS did not capture the use of Tylenol. For another resident, review of a quarterly MDS with an assessment reference date of 10/15/25 showed that Section N0415 (High-Risk Drug Classes) documented the use of an opioid medication. However, review of the resident’s October 2025 Medication Administration Record did not show that the resident had been prescribed an opioid during that period. In both cases, MDS staff later confirmed that these were errors in MDS coding, demonstrating that the assessments did not accurately reflect the residents’ clinical status and medication use as documented in their medical records.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident receiving narcotic medication. The resident, admitted in March 2026, had a fall on 3/6/26 and was sent to the hospital on 3/9/26. Review of the March 2026 Medication Administration Record (MAR) showed documentation of a single 25 mg dose of Tramadol administered on 3/8/26 at 9:23 AM. However, review of the resident’s Controlled Drug Receipt/Record/Disposition Form, kept on the nurse’s medication cart and not in the medical record, showed that Tramadol 25 mg was administered three times between 3/8/26 and 3/9/26: at 11:00 AM and 9:00 PM on 3/8/26, and at 9:00 AM on 3/9/26. In interview, the DON stated that staff are expected to document narcotic administration on the MAR and confirmed that only one of the three Tramadol doses reflected on the controlled drug record was documented on the resident’s MAR. This discrepancy between the controlled substance record and the MAR, with missing documentation of two administered doses of Tramadol on the official medical record, constituted the failure to maintain a complete and accurate medical record for the resident.
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